educational solutions for workforce development pharmacy stroke anne kinnear lead pharmacist nhs...

Educational Solutions for Workforce Development

Pharmacy

STROKE

Anne Kinnear

Lead Pharmacist

NHS Lothian

PharmacyAim

To update pharmacists on Stroke: the disease and its management and explore ways to implement pharmaceutical care for this patient group as part of normal working practice.

PharmacyObjectives

• Describe the disease, identify risk factors and signs and symptoms associated with Stroke.

• Define the current therapeutic management of acute Stroke and secondary prevention measures.

• Identify pharmaceutical care issues and respond to symptoms in patient scenarios and identify appropriate management solutions.

• Explore how to implement the principles of a pharmaceutical care needs assessment tool in practice.

Pharmacy

Stroke

Third commonest cause of death in Scotland15,000 stroke patients in Scotland annuallyOne of leading causes of disability in adults

Pharmacy“Time is Brain”

PharmacyStroke

2 million neurones per minute

Pharmacy

How do you know if someone is having a stroke?

PharmacyWhat is FAST?

F acial weakness - can the person smile? Has their mouth or eye drooped?

A rm weakness - can the person raise both arms?

S peech problems - can the person speak clearly and understand what you say?

T est – all 3

PharmacyStroke WHO Definition

A neurological deficit (usually loss of function) caused by reduction in blood supply to the brain. This is usually because a blood vessel bursts or is blocked by a clot. This affects the supply of oxygen and nutrients, causing damage to the brain tissue.

Pharmacy

Chest Heart and Stroke Definition

A stroke is a brain attack.

It happens when the blood supply to the brain is disrupted.

Most strokes occur when a blood clot blocks the flow of blood to the brain.

Some strokes are caused by bleeding in or around the brain from a burst blood vessel.

PharmacyStroke

• Transient Ischaemic Attack (TIA) – a stroke which resolves within 24 hours

(10% risk of stroke within 7 days)

• Minor Stroke – a stroke resulting in persisting symptoms but not causing significant disability

• Major Stroke – a stroke resulting in persistent deficit

PharmacyDiagnosis

Computed Tomography scan

(CT scan)

`Immediate`

Cerebral infarct

Cerebral Cerebral haemorrhagehaemorrhage

Diagnosis – stroke typeDiagnosis – stroke type

STROKESTROKE

CT CT scanscan

PharmacyStroke

PharmacyAtherosclerotic thrombosis

PharmacyStroke

1 - Anterior cerebral artery 2 - Anterior communicating artery 3 - Internal carotid artery 4 - Posterior communicating

artery 5 - Middle cerebral artery 6 - Posterior cerebral artery 7 - Superior cerebellar artery 8 - Basilar artery 9 - Anterior inferior cerebellar

artery

Pharmacy

Cerebrum – intellect, speech, emotion, sensory, movementCerebellum – balance, co-ordinationBrain stem – respiration, heart rate, blood pressure, wakefulness

Cerebrum - left hemisphere – speech and language

Pharmacy

Risk factors

Risk Factors For Stroke: Treatable

DiabetesHypertension SmokingLifestyleDietCholesterol Heart disease, esp. atrial fibrillation Transient ischaemic attacks

Less Well Documented

Excessive alcohol intake / drug abuse

Acute infection

PharmacyRisk factors

Risk Factors for Stroke That Cannot Be Changed

Increased age

Being male

Race (e.g., African-Americans)

Family history of stroke

Pharmacy

Evidence Base for Treatment

ACTIVE

PROGRESS

CHARISMA

SPARCL

ESPRIT

PROFESS

PharmacyAcute Secondary Prevention

PharmacyAcute treatment

Thrombolysis

Antiplatelets

Blood pressure

Hydration

Oxygen

Blood glucose

Temperature

PharmacyThrombolysis

• Lyses clot by digesting fibrinogen• Intravenous recombinant tissue plasminogen

activator (tPA - Alteplase) 0.9mg/kg after test dose• Within 4.5 hours (6hrs if IST-3 clinical trial)

• Reduces death and disability at 90 days• 2% incidence of symptomatic haemorrhage at 24 hrs• 8% incidence of symptomatic haemorrhage at 7 days

PharmacyAntiplatelets

Aspirin 300mg within 48 hours continued for 14 days

• reduces 14 day mortality and morbidity

No evidence for: • Anticoagulants• Combinations of antiplatelets or antiplatelets

with anticoagulants• Neuroprotectants

Pharmacy Blood pressure - not actively managed in acute phase

Hydration – IV Sodium Chloride 0.9% is preferred to glucose 5%

Blood glucose - treat if blood glucose is >11mmol/L

Oxygen - supplemental Oxygen if saturation <95%

Temperature – prescribe antipyretics

PharmacySecondary Prevention Treatment

Evidence

Cochrane ReviewsDipyridamole MRClopidogrel vs Aspirin

Randomised Clinical Trials MATCH Aspirin + Clopidogrel vs Clopidogrel CHARISMA Aspirin + Clopidogrel vs Aspirin ESPRIT Aspirin + Dipyridamole MR vs either alone PROFESS Aspirin + Dipyridamole MR vs Clopidogrel

Aspirin and Dipyridamole MR in combination significantly reduces risk of vascular events compared to aspirin alone (approx 25% risk reduction)• without an increase in bleeding The combination of Aspirin and Clopidogrel is no more effective than either alone• is associated with an increase in moderate/life threatening bleeding•only 25% patients in studies had a history of previous stroke•used in acute coronary syndrome (NSTEMI) or carotid stenosis

The combination of Aspirin and Dipyridamole MR vs Clopidogrel showed no difference in efficacy

Recommendations

Clopidogrel 75mg daily OR Aspirin 75mg daily and Dipyridamole 200mg MR twice daily should be prescribed after ischaemic stroke for secondary prevention of vascular events

Aspirin alone – if dipyridamole intolerance (headache 26% withdrawal ESPRIT trial) - or if carotid stenosis 70% or unstable angina

The combination of aspirin and clopidogrel is not recommended for prevention of ischaemic stroke or TIA

Pharmacy

StatinsEvidence2 x Systematic reviews (170000 pts)Randomised Clinical Trial – SPARCL (4700 pts)

• Statins significantly reduce relative risk of ischaemic stroke by 21% but stroke death is not reduced

• Effect occurs without an increase in haemorrhagic stroke

• Statins reduce coronary events and all cause mortality

• Effect occurs irrespective of baseline cholesterol level (proportional to LDL lowering)

Pharmacy

Statins

Recommendations

A statin should be prescribed to patients who have had an ischaemic stroke irrespective of cholesterol level

Which statin?

Simvastatin 40mg – high risk coronary event

Atorvastatin 80mg – TIA / ischaemic stroke

Should not be used in patients with a prior history of intracerebral haemorrhage

Pharmacy

AnticoagulantsNon-cardioembolic ischaemic stroke

EvidenceSystematic review Anticoagulant vs antiplateletRandomised clinical trial – ESPRIT

• Anticoagulants no more effective than aspirin• No difference in all cause mortality between antiplatelets

and low or medium anticoagulation• Higher mortality and major bleeding at intensive

anticoagulation

RecommendationAnticoagulation not recommended

PharmacyAnticoagulantsAtrial fibrillation and ischaemic stroke

EvidenceRE-LY trial

• Warfarin MORE effective for prevention of all vascular events and recurrent stroke

• No significant increase in intracranial bleed• Not within 2 weeks

RecommendationWarfarin should be offered with target INR of 2.0-3.0OR Dabigatran (direct thrombin inhibitor) 110mg or 150mg twice a day may

become an alternative to warfarin

PharmacyAnticoagulants

Atrial fibrillation and ischaemic stroke

Evidence

RE –LY trial (NEJM 2009)

• Warfarin versus Dabigatran in AF with primary outcome of stroke

Recommendation

Equal efficacy for warfarin and dabigatran with no worse safety profile for the dabigatran

Pharmacy

Antihypertensives

Evidence

Well established link between BP reduction and stroke primary prevention

Systematic review (7 trials)Randomised Clinical Trial - PROGRESS Perindopril/Indapamide

• Lowering BP reduced recurrent stroke and major vascular events• No effect on vascular or all cause mortality• Reduction in stroke related to difference in systolic BP between

groups

PharmacyAntihypertensives

Recommendation

BP should be assessed in all patients and therapy with an ACE inhibitor and thiazide diuretic should be considered regardless of BP

Target blood pressure is <140/85 – diabetics <130/80 mmHg

Pharmacy

Summary Secondary Prevention of Ischaemic Stroke

Aspirin 75mg + Dipyridamole 200mg twice daily (or Clopidogrel 75mg if ACS)

Simvastatin 40mg / Atorvastatin 80mgThiazide diureticACE inhibitor

Warfarin or dabigatran if AF

PharmacyPharmacist Role

Public health, education and information

Pharmaceutical care

Research

Multidisciplinary team membership

Pharmacy

Public Health, education and information

Awareness and promotion of:

• Public Health campaigns• CHSS campaigns and resources • Risk factors – action to take• Stroke Identification – FAST test• Lifestyle advice – smoking, weight loss/diet, vitamins

Pharmaceutical care

Research

PharmacyPharmaceutical Care

• Transfer of patient information primary/secondary care interface

- continuity of care- reduction of medication errors/discrepancies

• Identification and resolution of pharmaceutical care issues

- level and type of resultant disability

Pharmacy

Modified Rankin Score (mRS) Disability Score

Score Symptoms

0 No symptoms

1 No significant disabling symptoms

2 Slight disability

3 Moderate disability

4 Moderate/severe disability

5 Severe disability

6 Dead

PharmacyDisability

Dysphasia Aphasia

Dysphagia Aphagia

Hemiparesis

Hemiplegic

Hemianopia

Speech

Swallow

Weakness

Paralysis

Visual difficulties

PharmacyPharmaceutical Care Issues

Speech

Comprehension

Swallow

Communication/counselling• carers

Ability to take medicines• aspiration risk and liquids• formulations• bioavailability eg phenytoin• NG and PEG tube feeding

PharmacyStroke

Weakness or paralysis

Visual problems

Ability to operate devices• inhalers, insulin

Ability to open containers

Ability to read instructions• labels, leaflets, charts

Pharmaceutical care

Research

PharmacyResearch

Practice development project – MSc Strathclyde University• Standardised pharmaceutical care plan validation• Validation of care issues for transfer – needs assessment tool

Pharmacist Research Fellow• Design and validate transfer document for stroke

PharmacyResearch

Audit of prescribing adherence to stroke guidelines and design and evaluation of a pharmaceutical care model

• Prospective evaluation of prescribing in acute stroke unit patients against guidelines and development of a pharmaceutical care plan

• Retrospective evaluation of prescribing in the same patients

following discharge to primary care and design of documentation to facilitate information transfer between secondary and primary care

PharmacyResearch

Primary Care - Results• adherence 75% (hospital 79% 94%)• lower for quality indicators not included in GMS contract• lower for communication criteria

Primary Care - Conclusions

Improvement areas for prescribing• use of warfarin in atrial fibrillation• achievement of clinical target blood pressure and glycaemic

control to audit and clinical standards

Pharmaceutical care

Research

PharmacyMultidisciplinary team membership

SIGN – Scottish Intercollegiate Network

Managed Clinical Network for Stroke (MCN)

National Advisory Group for Stroke

Stroke Unit Multidisciplinary Team

PharmacyStroke Key Messages

Time is brain

Think FAST

Brain attack – dial 999

PharmacyUseful Contacts

educational solutions for workforce development pharmacy stroke anne kinnear lead pharmacist nhs...

educational solutions

stroke definition

risk of stroke

stroke patients

brain slide

minute slide

days minor stroke

persistent deficit slide

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